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Step Therapy

Step therapy, or fail first, is a process that requires individuals who have been prescribed certain medications to try and fail one or more medications preferred by the insurer before receiving the originally prescribed drug.

There is no "one size fits all" treatment option for epilepsy, and the response to epilepsy medications can be different for each person. Maintaining seizure control with minimal side effects requires careful evaluation and monitoring by the physician and patient. To change, limit, or deny access to medications could be extremely dangerous. People living with epilepsy who have their medications switched, or who experience a delay in accessing their medication due to onerous step therapy requirement, are at a high risk for developing breakthrough seizures and related complications. Step therapy also significantly increases medical costs related to preventable seizures, along with lost wages and productivity, not just for the individuals living with epilepsy but also their families and communities.

The Epilepsy Foundation opposes step therapy and similar policies intended to restrict access to physician-directed care that unnecessarily prolong ineffective treatment, and prevent individuals from immediately starting the treatment their practitioners think is best.

State Step Therapy Model Bills

This legislative cycle the model step therapy bill has been introduced in several states, and we anticipate it will be introduced in a few more. The bill would require insurers to streamline step therapy requirements by providing a process for doctors and patients to override step therapy requirements when medically necessary, along with other protections.

The map below highlights where legislation has been enacted in 2018 and previous years. The Epilepsy Foundation closely monitored and advocated for legislation designed to reduce the burden of step therapy on people with epilepsy on both the state and federal levels.

Federal Step Therapy Bill

In 2017, Representative Brad Wenstrup (R-OH) introduced the Restoring the Patient's Voice Act of 2017(H.R. 2077), which would amend the Employee Retirement Income Security Act (ERISA) to require a group health plan to provide an exception process for any medication step therapy protocol. The Epilepsy Foundation has signed on to a group letter in support of H.R. 2077 -- read the letter below.